Optometry Intake and Consent Form

First NameLast Name

Date of Birth

Date

What is the reason for your visit today?

Do you have any of the following conditions? (Please check all that apply)

Are you currently taking any medications?

YesNo

If yes, please list the medications you are taking.

Do you have any allergies to medications?

YesNo

If yes, please list what allergies.

Have you had any previous eye surgeries or treatments?

YesNo

If yes, please describe.

Are you currently wearing glasses or contact lenses?

GlassesContact LensesNeither

Does anyone in your family have a history of the following? (Please check all that apply)

How many hours per day do you spend using digital screens (computer, phone, etc.)?

Are you exposed to high levels of sunlight or UV radiation frequently?

YesNo

Do you drive at night frequently?

YesNo

Do you experience any of the following? (please check all that apply)

Which of these apply to you? (Please check all that apply)

SmokeDriverDrink AlcoholPregnant

I, the undersigned, consent to the optometric services to be provided by the healthcare professionals at KCS. These services may include:

Comprehensive eye examination
Prescription of corrective lenses (glasses or contact lenses)
Screening and management of eye diseases such as glaucoma, cataracts, and diabetic retinopathy
Dilation of pupils for better examination of the internal structures of the eyes
Referrals to ophthalmologists or other specialists if necessary

Disclosure of Risks and Benefits

I understand that certain procedures, such as dilation or the use of eye drops, may cause temporary discomfort, blurred vision, or light sensitivity. The risks and benefits of these procedures have been explained to me, and I will have the opportunity to ask questions.

Privacy and Confidentiality

I acknowledge that my personal and medical information will be kept confidential in accordance with HIPAA regulations and will only be shared with necessary healthcare professionals for the purposes of my treatment, billing, or healthcare operations.

Patient Rights

I understand that I have the right to:

Be informed about my diagnosis, treatment options, and any potential risks
Refuse or withdraw consent for treatment at any time
Receive a second opinion if desired

I certify that I have read and understand this informed consent form. I have had the opportunity to ask questions and consent to the optometric services described above.

Patient/Legal Guardian Name

First NameLast Name

Signature

Date

Optometry Intake and Consent Form

Patient Information

Consent for Optometry Services

Patient Consent